Provider Demographics
NPI:1558987487
Name:RACIC, IVANA (DDS)
Entity Type:Individual
Prefix:
First Name:IVANA
Middle Name:
Last Name:RACIC
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 W G ST STE H
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6026
Mailing Address - Country:US
Mailing Address - Phone:843-489-6692
Mailing Address - Fax:
Practice Address - Street 1:230 W G ST STE H
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6026
Practice Address - Country:US
Practice Address - Phone:843-489-6692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2021-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1049321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice